Understanding and Treating Attachment Problems in Children: What Went Wrong and How Problems Can Be Fixed

By Dave Ziegler, Ph.D.

This somewhat complex article reviews the basic tenets of traditional attachment theory and describes both its strengths and weaknesses. Revisions to attachment theory are suggested and detailed explanation is provided of both the causes and treatment of various types of attachment problems. It is both a technical road map and a practical guide to the journey.  Although complex, It has been written to be understandable to professionals and parents alike. (31 pages)   Link to full article here.

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Adoption and Attachment

By Dave Ziegler, Ph.D.

 The Adoption Courtship Model

Out of necessity, Jasper Mountain Center (JMC) staff have attempted to isolate why some adoptions worked during the first five years of our program and why most didn’t.  The result of two years of considering this question has been the development and implementation of an adoption model for children who

  • are emotionally disturbed;
  • are hard to place; and/or
  • have single or multiple adoptive failures

The operating principles for our Adoption Courtship Model are the following:

  • Standard adoptive procedures are insufficient for special-needs children and their prospective families.
  • The odds are often against a successful adoption with these children, without preparation, training, and professional support.
  • The child and the family must be prepared for the reality of this adoptive relationship.
  • The adoption commitment must be made by both the child and the family and can only be made based on a relationship, not on information or interest.

The model has three phases:

  1. Phase I.  The child is prepared for the adoption by understanding his or her role in making it work or not work.  The child’s considerable power in the situation is made clear.  The family goes through the regular certification steps and is selected by the adoption committee.  The family meets with the caseworker and JMC staff to learn what to expect from the initial meeting.  The child is also prepared for this meeting.  The two sides meet with the caseworker and family therapist.  The child begins to build trust by getting to know the family as a unit, then the family members as individuals, and finally in the home environment.
  2. Phase II.  This is where the reality must begin to come in.  Both sides have an image of what they are doing and who they are doing it with, but it must become very clear and very real.  This phase is characterized by extended visits and family counseling.  The process starts with a focus on the strengths and positive attributes of both sides, moves to the faults and flaws of both sides, and finally underscores the realities of the combination of strengths and weaknesses of the adoption.
  3. Phase III.  There are three necessary commitments for the adoption to work.  The initial commitment on the part of both child and family is a commitment of interest, time and effort in regard to adoption.  The second is a commitment to relationships with the child, and the child to the family.  The final commitment is to family for life.  The last commitment is the final step in a successful adoption of special-needs children, not the first step as in regular adoptions.  This commitment must be made to a person, not a concept.  This is important for these children because the reality of how difficult adoption is with disturbed children must be stronger than the commitment to the adoption as a concept.

Suggestions and Techniques

PHASE I. 

Preparation.  Phase I starts long before the family and the child meet.  One of the keys here is preparation.  There is an important question to ask before the specific adoption work begins:  “Has everyone received some preparation for the adoption?”  Too often the family receives more preparation than the child.  Preparing the child for an adoptive placement should ideally begin a year prior to meeting family, with specific counseling on the issues that will come up.  Along with adoption classes, it is valuable to have the prospective parents meet with the adoption worker or counselor who will work with the transition process to prepare the family for the probable struggles that are ahead.

Initial meeting.  After the adoption committee gives its blessing to a match and the Adoption Courtship Model is decided on, it is then important for the family to meet with the adoption worker(s) and the counselor who will provide the transition counseling and discuss the model, the process, and the goals.  Keep in mind that most adoptive families are in a mild to huge rush to have the child.  A rushed courtship is almost always problematic.  Gain the family’s agreement and commitment to the process or don’t use this model (in general, the bigger the rush the family is in, the more concerns there are about their readiness).

The initial meeting of child and family.  Again the suggestion is for the worker(s) and counselor to be actively involved.  Often for this population, meeting the parents alone before children are involved is less complex and overwhelming for the adoptive child.  There should be informal time between the child and the parents, as well as the worker and counselor outlining what will be happening over the next few months and why.  Keep the meeting from being stuffy or too formal.  Make it clear that the goal is to see if in the long run this is a good match for everyone concerned.  All sides will have a voice (empower the child to influence his or her future and you will have a much better response).

Process.  Start with meetings in counseling to get to know each other.  Have the whole family come the second time.  Use techniques to rapidly point out the different personalities in the family (who is the clown, who is grumpy in the morning, etc.)  A technique here is to have the members of the family write on a sheet of paper the things they like and dislike about the family member to their left and right.  The counselor reads the items and has the family guess whom it was written about.  Start with afternoon visits away from the family home.  Go to daylong visits and then an overnight visit, again away from the family home.  This is to equalize the playing field.  In the family home only the adoptive child is unfamiliar with the environment.  In a park, restaurant, or motel at the beach, the focus is on the relationships, not on getting used to the family’s turf.  The adoptive child should have a chance to get to know all family members at least a little, both individually and together, before going to the family home.

Counseling.  The initial meetings and discussions should take place in the counselor’s office.  After each visit there should be a session.  The counselor plays the role of bringing the family and child together and facilitating the process so both sides know that the situation is organized and under control.

PHASE II.

Counseling.  Counseling continues to be frequent but not necessarily occurring each time.  Involve foster care providers to help make the child’s strengths and weaknesses clear.

Process.  GET REAL!  Arrange extended visits, primarily in the home environment.  Get away from special events and get down to everyday life.  The goal of this phase is to make it clear what this adoptive combination will really be like.

Techniques.  Stress the strengths and weaknesses of the match, the family, and the child.  It may be difficult or embarrassing, but it is time to air everyone’s strong points as well as dirty laundry.  Use techniques like having everyone answer such questions as “When I get really angry, I …,” “I show sadness by …,” “When I am grumpy, the best way to deal with me is …,” etc.  Role-play some of this.  Have children act like Mom in the morning before coffee.  How do the parents fight with each other?  Have the adoptive child act out some of his less impressive qualities, such as being rude, disrespectful or hurtful.  Whatever family members will see later should be talked about, even acted out, now.

PHASE III.

Process.  Now that everyone has met and should know a lot about one another, the emphasis shifts to commitments.  There are three levels of commitment:  (1) time and effort, (2) relationship, and (3) life commitment.  Commitment 1 should have long since been made and operationalized.  It will be important to review and evaluate how everyone has handled this commitment because it will be an indicator of the next two.  How interested is everyone in a commitment to relationship?  In the case of attachment-disordered children, this must be reviewed carefully to have realistic expectations.  It is clearly time to begin putting out on the table the issue of life-long commitment.  Again, the commitment must be to people, not to the concept of adoption.

Counseling.  Here is where the skill of the counselor is most needed.  There is much complexity in commitments.  There may be resistance on everyone’s part to addressing this.  If things are going smoothly, why upset the apple cart?  No one really wants the final analysis to be halting the adoption because it is not overall a good match, but this may be the case.  The counselor must be firm and willing to be the bad guy.  The capacity of the child to commit himself may be problematic, and the parents may have better intentions than abilities.

Ritual.  If the adoption gets a green light, then some have found a formal recognition of the adoptive commitment an important step.  Consider having a ceremony.  Invite friends and throw a party.  Our culture does this for most important events.

A Final Thought

Adoptions can work with special-needs children, but the work is never completed (yet when is any parent’s job done?).  Despite an excellent placement for both the child and the family, the work has only begun.  The transition into the home will set an all-important tone, but don’t fool yourself that the job will get easier.  Our experience is that new struggles come up with each physical and developmental stage of the child.  But that just makes adoption like life—a new challenge around every corner.

A Residential Care Attachment Model

By Dave Ziegler, Ph.D.

Attachment disorder is much like many other issues in our society wherein we coin a new term for a very old problem and then scare ourselves about how bad it is.  Don’t misunderstand—an attachment disorder is a serious problem, but it is not what it has been presented to be by sensational stories and made-for-TV books.  Children with attachment disorders are just that—children.  They are difficult, yes; they can be hurtful, yes again; but they are not lost causes, much less developing Ted Bundys.  Our program works with these difficult children every day, and we see clear progress in nearly all of them.

There are tens of thousands of children in our systems of “care”, which means we have far too many children who have not been cared for where it counts—in their families.  These children often have defenses and tough shell that few can penetrate.  Without a knowledgeable and understanding care provider, this can lead to problems in reaching out and bonding.

These children have attachment themes rather than an attachment disorder.  Without someone reaching them while they are still more connected to family than to peer group (usually under the age of twelve), these children may well become the delinquents and criminals of tomorrow.  The halls of our prisons today are filled with the youngsters of our systems of care in the past.  For these children it is either pay now—with resources for social workers, therapists, and trained foster parents—or pay later—with free room and board in our institutions.  These children may well be the criminals of tomorrow, but they should not be confused with children with a true attachment disorder.

Children with a severe attachment disorder have never had a successful attachment to anyone.  Children with a mild to moderate disorder have had only partial and never truly rewarding attachments in their short lives.  These children start life in the first twelve to eighteen months with failure in the most basic of instincts in human beings—bonding immediately, first of all to survive and then to find a successful place in the interdependent world of other human beings.  When things go badly to begin with, the instinct to bond (promoting physical survival) is overridden by avoiding the pain and neglect of attaching (emotional survival).  The seeds of attachment are often sown long before the results are observed.  Without a disruption in the cycle of an attachment disorder, it may grow into a lifelong and unsuccessful search for a place in the social network of our society.

I believe we are still in a phase where as a society we are not sure how to help these children.  In our confusion and to some extent desperation, we have developed what appear to be desperate therapies, and some parents, professionals, and programs believe these intrusive approaches are all that can work.  I suggest that we take our desperation and first work to clearly understand the problem and its causes and then commit the necessary resolve and patience to test our solutions.  I would like to share with you one such patient testing ground, which is a small residential treatment program called Jasper Mountain Center.

How Jasper Mountain Started

 The center was founded by three babyboomers who were raised by their own families with varying levels of health as well as dysfunction.  Armed with college degrees, professional experience and seemingly unlimited energy, the three of us set out to make a difference in the world, following the advice of Mother Theresa—one person at a time.  The goal was to create a seamless integration of our home life and our professional work.  This goal was quite effectively reached, and we are not clear to this day whether this has been as good for us as it has been for the program’s children.  The practical steps are easy enough to recount:  endless meetings to determine the criteria to find the healthiest place in the United States to live, moving to the promised land in southern Oregon, and purchasing a rural ranch.  After six months of acclimating and very long days fixing up the old ranch, we informed the state child protection agency that we were ready for their biggest challenges.  The reaction from the state’s workers was one of equal parts elation and suspicion.  Elation that people interested in accepting very disturbed children into their home would also be experienced professionals with counseling backgrounds.  And suspicion as to why people who had a choice would want very disturbed children in their home!  Many years later there are those who still have suspicions.

Jasper Mountain Center was founded in 1982 on an eighty-acre ranch southeast of Eugene, Oregon.  The scenery was beautiful enough, with two major rivers, heavily wooded forest, waterfalls, an artesian spring, miles of hiking trails, and sheer cliffs rising to a thousand-foot mountain, all of which were on the property.  The ranch even had history as part of the second homestead in this region of Oregon and the end of the Oregon Trail for Cornelius and Jasper Hills.  To this beauty and history we worked to bring hope to some very confused and abused children.  From the beginning the children came to Jasper Mountain telling their stories of abuse and pain.  The program quickly turned its focus to healing the scars of sexual abuse, which were present in almost all the children.  We soon saw that some children healed very differently from others and that some didn’t seem to heal at all.  Of all the children, there were those who didn’t look at you, would push away any affection, and were quick to use and abuse you as they had been themselves.  In the early 1980s we began identifying children who had bonding problems, and invariably they were the most difficult of our difficult children.

How the Program Works

Jasper Mountain is based on principles of health in body, mind and spirit.  The program ensures clear air, clean water, plenty of exercise, and treatment components in a context of family where the parents are professionals.  This family focus has turned out to be the most important ingredient in the therapeutic stew.  Not that being in a family makes much difference to attachment-disordered children, but in the final analysis it is the ability of the family and its staying power that will make the difference in the bonding process.  In the early years the three of us did everything without outside help.  At this point the program has the state’s highest classification for supervision and treatment which requires one staff for every three children.

The program uses four basic categories of intervention:  environmental, behavioral, psychotherapeutic, and self-esteem.

  • Environmental intervention creates a therapeutic Disneyland, but rather than the happiest place on earth, we strive for the healthiest place on earth.  There is close scrutiny to every environmental aspect of the program, from the architecture of the buildings to diet, and from the amount of natural light to the control of violent themes that reach the children from the outside world (e.g., having no commercial TV).
  • Behavioral interventions include the mundane but important behavior management systems wherein the children earn levels that determine privileges.  At Jasper Mountain the children have a behavioral system for the residence and another for the on-site school.  Although the level system is the most traditional part of the program, the children get up each morning and go straight for the chart to find out what level they are on for the day.  Modifying behavior is an important step, but is only a beginning step in treatment.  Behavioral ways to require a give-and-take framework are essential with children with an attachment disorder.
  • Psychotherapeutic interventions include all the individual, group and family therapy interventions, as well as art and play therapy.  They also include occasional chemical interventions and sessions with the program’s psychiatrist.  Each child has an individual therapist in addition to our psychiatrist to promote skills at developing relationships with various adults.
  • Self-esteem intervention is where some of the unique aspects of the program can be found.  These include a variety of routes to the self-worth of the child, including biofeedback, concentration and meditation training, therapeutic recreation, an equestrian program, hiking and rock climbing, jogging, gardening, visual and performing arts, computer competency, positive video feedback to enhance the self-image of the children, and many others.

But even with magical interventions like the above (and there is something that every child will find magical on this list), there is no guarantee that an attachment-disordered child will use any of these to heal his or her disposition toward others.  With this backdrop of our basic residential treatment program comes the specific approaches used for these challenging children.

 What Makes the Difference?

At Jasper Mountain we are often asked why children with attachment disorders who can strike fear into the hearts of parents, caseworkers, and therapists are not feared in our program.  And here is step one in making a difference with these children—they must not be feared or their controlling nature takes over.  Relationships with these children are often initially no less than warfare.  In this struggle for dominance, if the child wins, everyone loses, and if the adult wins, everyone wins.  I see it as just that simple.  Of course, how to win the struggle with these masters of control is not simple at all.  That we do not fear these children in our program may come from the fact that no matter how good they are, so far none has been able to win the control war at Jasper Mountain.  In most cases the children, who are usually very bright, realize within weeks that they may be able to control an individual staff person for a while but not the whole program.

Another factor critical to our success with these children is to work as a team and control all variables in the child’s life producing a unified approach.  In our program there is only a building change from the residence to the school; the approach and staff act in unison.  We take time to work with caseworkers and family so that the methods the child has used to irritate, control and keep others distant do not work on campus or off.

Treatment with these children not only must strip them of their remarkably intricate insulation and defenses but also must provide a real and attractive alternative.  How can getting close ever look attractive to a child with an attachment disorder?  The answer is as simple as the first principle of negotiation—you get some of what you want only when I get some of what I want.  Despite attempting to look otherwise, these children want lots of things.  They are generally extremely motivated by material belongings, although they believe that if you knew this, it would make them vulnerable, and thus they pretend to be apathetic to almost everything.  Don’t believe it.  At the same time, they will take without giving if you let them.  You must teach them reciprocity and hold them accountable.  There must be a constant pressure to connect.  With normal children (has anyone seen one of these lately?) coercion is not a positive or useful approach.  But with these children they get dessert only after a polite request; they go to the movie only after doing a chore for you; they play fifteen minutes of Nintendo only after sharing two important events at school today.  The approach is clear:  You don’t get something for nothing (except love).

The effectiveness of treating these children comes down to every interaction between adults and the child.  This means that every contact between a program staff member and the child is a very small part of the puzzle but critical to the overall picture.  Manipulative children do not change if their tricks work on anyone.  If the therapist and parents work together but the school is out of the loop, and the child will never change, due to intermittent variable reinforcement, the same principle that brings confident gamblers to Las Vegas to lose their money time after time.  The child tells himself that he will prevail in the end.

As stated before, these children are usually quite smart, and when they understand that they must work to get what they want, here is their sequence:  First they start by not doing it, to see if you get flustered; then they do it halfway and grudgingly (punishing you); then, if they must do it right, they will do it with a bad attitude; and eventually they just do it.  These progressive steps occur only when they have to do their part to get what they want.  When this pattern is repeated over and over for years the psychological principle of cognitive dissonance steps in, whereby if your behavior changes, eventually your attitude must change and if your attitude changes, then our behavior must eventually change as well.

You must demand that children with attachment disorders do just what you want of them (which are progressive steps toward relationship).  They need not do it with an open heart or with honesty; they just need to do it.  What you begin to systematically show them is that they will not be abused when they are vulnerable and that the world where you get what you want by being close to others is far superior to using others and being emotionally and personally alone in the world.

The last factor that makes a difference is a four-letter word, time.  Time is a four-letter word in our culture because we don’t want to take the time to do most anything right.  We are irritated by the traffic light that delays us three minutes; we want the flu medicine that gives us fast, fast relief; and incredibly we are impatient when we have to wait two and a half seconds to store our documents on our old model computer.  Is it any wonder that we flinch at the prospect of taking years to treat an attachment disorder?  This may have something to do with the do-it-quick “holding” therapies that promise some bonding after an intensive weekend, or at least after the twelve-week special.  Some may believe that the patterns of withdrawal and distance in a true attachment disorder can be extinguished relatively quickly and a new pattern of interdependency and vulnerability learned soon after, but I do not believe there is any shortcut to the years of concentrated effort described above.  For the Star Trek generation, where any galactic problem is solved within the hour, years of effort are inconceivable, but they are truly necessary.

To be fair to all us parents who have a child with an attachment disorder in our home (I have one by adoption), we would have a better chance at putting in years of effort if only we saw some progress, even tiny successes, or at least the reassurance that we were heading in a direction other than futility and exasperation.  This is precisely what our program tries to give parents—a road map.  We all know that human beings that take at least twelve years to raise before the onset of their teen years.  Our current thinking is that the relearning process may take five to seven years.  I believe parents can learn to persist if they are shown a way that works, as long as they don’t get a false message that there is a quick fix.

The Jasper Mountain method works.  Whether it is the place, the people, approach, the time invested, or all of the above simultaneously.  The important thing is that the program wears the child’s defense down before the child wears the staff down.  We do not describe the children as “cured” when they leave Jasper Mountain.  Attaching is not only an instinct; it is also a skill.  We should not leave children in a rather scary and indifferent world without their defenses unless they are given new tools to succeed in the game of life.  It takes a very long time to learn how to bond even after the children decide they want to.  This is usually a process of unlearning and then relearning.  It is important that we not lead these children down this long road to healing if we are not prepared to go the distance.  In residential care this means that you never completely close a case.  Our program’s graduates keep in touch, come by, borrow money, and bring by their fiancé to meet the family.  We have invited our children into our extended family, and nearly all accept.

In adoptions we must understand that there may be no other chance for these children.  Due to the time it takes to free a child for adoption, to place the child in the right home, and to invest the five to seven years with him or her, there may not be time for a “Plan B” and starting the process over with another family.  This may sound like a great deal of responsibility for the adoptive family, but if real bonding doesn’t happen in the first adoptive family, it may never happen.

Perhaps the ultimate abuse is to take a child who is dependent on others for her very life, thwart her survival instinct by not placing her where she can form an attachment, fail to help her connect with others during her early years, and expect her to live the rest of her life emotionally and spiritually alone and separated from friends, a spouse, her own children, and even God.  It comes very close to a definition of hell, doesn’t it?  I hope you agree with all of us at Jasper Mountain that years of hard work are not too high a price to save the quality of life for a child with an attachment disorder.

Appropriate and Effective Use of Psychiatric Residential Treatment Services

By Dave Ziegler, Ph.D. 

Executive Summary 

Stakeholders in a comprehensive system of care view psychiatric residential treatment as a dynamic and critical component interfacing with an effective overall mental health system for children (Butler & McPherson, 2006).  To be most effective PRTS must be targeted, responsive, and individualized to the needs of the child and the family and have the following characteristics: 

  • Integrated into the overall system of care and includes a continuum of step-up and step- down services within the same provider organization.
  • Offers a comprehensive and ecological model of multi-model treatment interventions into an integrated whole, designed to meet the individual needs of a child and the child’s family.
  • Commitment to national standards of excellence, a continuous commitment to quality improvement, and have an identifiable treatment philosophy and approach based upon research and empirical evidence.
  • Emphasizes the environment around the child that will necessitate family interventions, partnering with families during and after residential services to best meet the child’s needs.
  • Makes an impact on the child’s positive thoughts and perceptions, emotional self-regulation, and pro-social skills and behaviors.

Psychiatric residential treatment services can play several effective roles within the overall system including: a. intensive treatment while maintaining safety, b. a component of a step up/step down plan for a child, c. Treatment of serious disorders that require coordinated multimodal interventions, d. assessing medication level while providing a stabilizing environment, e. alternative to psychiatric hospitalization, and f. a treatment of last resort for children for whom other interventions have been ineffective. 

Less appropriate uses of PRTS include: a holding place for a child waiting for a community placement, destabilizing the child by rapidly altering medications or delving into deeper psychological states without sufficient time to re-stabilize, and when the length of time in PRTS is predetermined before admission due to cost, utilization, or other factors unrelated to the needs of the child. 

The commonly repeated criticisms concerning the lack of research support for the effectiveness of PRTS lack validity.  The comprehensive nature of a multimodal integrated environment presents unusual challenges for isolating variables for causal research.  However, considerable research exists to support the overall effectiveness and efficacy of PRTS. 

When efforts are made to insure that the proper children are admitted to well designed PRTS, the child, the family, and the system of care can expect individualized, client-centered care that can result in positive outcomes for everyone. 

Introduction–Efficacy and Effectiveness of PRTS 

A common goal among all stakeholders in the system of care for children is to develop a comprehensive array of services that is sensitive to the needs of children and their families and provides needed care on a continuum of intensity based upon individualized needs.  For over fifty years there has been a debate concerning putting children in out-of-home placements.  The debate has continued whether this it is the orphan asylum of the past or the psychiatric residential treatment center of the present.  For a variety of reasons, some well deserved, residential care has been plagued by negative stereotypes and pessimistic sentiments (Frensch & Cameron, 2002). A persistent notion that institutional life is contrary to a child’s nature (Whittaker, 2004) has led to “an archaic and inaccurate perception of residential treatment as a single type of ineffective, institutional congregate care for children” (Butler & McPherson, 2006). However, the long standing debate over residential settings has gradually given way to an acknowledgement that the best system of care includes alternatives for the needs of all children regardless of the level of required intensity (Leichtman, 2006; Butler & McPherson, 2006; Lieberman, 2004).  Therefore the question has changed from whether residential treatment should used, to what is the appropriate and effective use of residential treatment in the new system of care. 

There is considerable literature and research support for the value of residential treatment of a broad variety of types and approaches, particularly for the sophisticated treatment settings that have met the highest national standards of excellence (CWLA, 2004; Lewis, 2004; Friman, 2000; Handweck, Field & Friman, 2001; Larzelere, Daly, Davis, Chmelka & Handwerk, 2004; Lipsey & Wilson, 1998; Lyman & Wilson, 1992; Pfeifer & Strelecki, 1990; U.S. Department of Health and Human Services, 1999). “Residential services are an important and integral component within the multiple systems of care and the continuum of services” (CWLA, 2005). This statement from the largest children’s advocacy organization in the country outlines the new thinking coming from policy makers, system managers, advocates, families, and providers.  The many arguments against the use of residential care of the past, including the comparison of one level of care over another, are out of favor due to improper comparisons and lumping divergent services (Handwerk, 2002; Butler & McPherson, 2006). In its place is a more inclusive and practically position that there will always be a number of youth who require the intensive structure and safety of the residential setting. Whether it is the Child Welfare League of America, the Building Bridges initiative, or the providers themselves (AACRC and others), there is wide support from stakeholders that residential care is an essential and important part of the overall system of care past, present and into the future. 

The psychiatric residential treatment program of today is not the same as programs of the past, including the very recent past.  This fact makes most comparisons to current care and the residential treatment of the past questionable in their validity.  The quality Psychiatric Residential Treatment program of today is not only integrated into the overall system of care, but includes a continuum of step-up and step-down services within the same provider organization.  Such an internal system of care allows for children and families to change levels of treatment intensity without changing key staff such as psychiatrists, therapists, teachers, and mentors.  For child with significant mental health needs, the level of treatment intensity will necessarily change over time if the plan of care is effective. 

What Constitutes Good Psychiatric Residential Treatment Services 

A quality residential program offers a comprehensive and ecological model (Stroul & Friedman, 1996; Wells, Wyatt & Hobfoll, 1991; Hooper, Murphy, Devaney & Hultman, 2000) of multi-model treatment interventions woven into an integrated whole, designed to meet the individual needs of a child and the child’s family.  The best programs start with a commitment to national standards of excellence, a continuous commitment to quality improvement, and have an identifiable treatment philosophy and approach based upon research and empirical evidence.  Effective programs will emphasize the environment around the child that will necessitate family interventions, partnering with families to best meet the child’s needs, and at times may include efforts to identify a family for children without one.  Good residential programs know the target populations that they are most effective with and have evidence based approaches for these populations.  Good programs make positively impacts on the child’s positive thoughts and perceptions, emotional self-regulation, and pro-social skills and behaviors.  The best residential programs are integrated into a community of stakeholders who have input into a continual unfolding of quality interventions in an overall environment of safety, respect and effectiveness. 

The Best Use of Residential Treatment 

For too long residential treatment has been relegated primarily to the placement of last resort.  In some situations it may be the case that a child has been unresponsive to treatment that is less intense or insufficiently environmentally integrated, thus necessitating the strengths of a residential setting.  The use of residential care as a “last resort” is still a possible role but there can be other roles as well: 

Intensive treatment while maintaining safety—Some children cannot be effectively and safely treated in a family setting.  Examples of this are serious violent behavior, firesetting, and significant sexual behavior. 

One component of an overall treatment continuum—At times the needs of a child may warrant treatment in a variety of settings from maximal to minimal levels of intensity as treatment progresses.  Residential care can be an important part of the plan including a back up to serious deterioration in levels of care in community settings. 

Treatment of serious disorders that require multimodal intervention—Children with the highest acuity of psychiatric needs often require a complex array of integrated services in a single setting.  An example of this are complex trauma disorders where up to a dozen specialized intervention strategies may be needed (Connor, Miller, Cunningham & Melloni, 2002). 

Safely assessing psychopharmacological intervention—A child may have serious emotional or behavioral destabilization when medications are significantly altered.  For children with several medications, it may be important to insure safety for the child and all concerned while the medication assessment process takes place. 

Alternative to hospitalization—A well designed psychiatric residential program can be an effective alternative to hospitalization for many serious children.  This can provide advantages including: keeping the child and family in the community, intensive care in a less restrictive setting, and a significant reduction in cost allowing a length of stay appropriate for the child. 

There are also ways that residential treatment should not be used.  It should not be a default setting for a child who has completed treatment but is waiting for a placement.  A residential setting should not be allowed to destabilize a child’s mental health, such as changing medications or opening painful psychological issues without sufficient time to follow through with the ramifications.  While there are children who have been shown in research to improve with short stays of six months or less in residential care (Blackman, Eustace, Chowdhury, 1991; Leichtman, Leichtman, Barker & Neese, 2001; Shapiro, Welker & Pierce, 1999), this is based upon a short-term approach of lowering the expectations of treatment through modest and selective goals such as primarily addressing the issue that caused the removal of he child from the family home (Leichtman & Leichtman, 1996).  However there is still a place for longer term treatment with specific childhood disorders that are not responsive to short-term interventions (Zegers, Schuengel, van IJzendoorn & Jansserns, 2006; McNeal, Handwerk, Field, Roberts, Soper, Huefner & Ringle, 2006; Greenbaum, Dedrick, Friedman, Kutash, Brown, Lardieri & Pugh, 1996).  Residential treatment is improperly used when the length of intensive residential treatment is predetermined before admission due to cost, utilization or other factor unrelated to the needs of the child. 

Efficacy and Effectiveness of Residential Treatment 

It is commonly stated that residential treatment has been shown not to be effective.  A closer look at efficacy and effectiveness tells a different story. While there have been weaknesses among the providers of residential care over the years, there have also been very effective services delivered in a residential setting.  This point raises an important distinction between an intervention and a setting.  Too often this distinction is misunderstood resulting in ‘apples and oranges’ comparisons (Butler & McPherson, 2006).  For example, an evidenced based intervention can be effective in a variety of settings, or the wrong evidence based intervention in a specific setting can be highly ineffective.  When discussing whether a placement is the best choice, both the setting and the interventions to be used are both important considerations. 

Science is informing the mental health world at an unprecedented pace.  Objective research is increasingly being considered to inform decision makers, parents and providers as to what to do more of, and what to discontinue.  Science considers all aspects of a situation to form an opinion, not just factors that confirm previous biases. Because there has been a fifty year debate over putting children in residential setting, both sides have presented data to enhance their argument, for or against. We must now move beyond previous biases and look toward objective science. 

Whether a treatment setting works depends upon both efficacy and effectiveness.  Objectively speaking there is research to support strong efficacy in residential care.  At the same time there are consistent questions as to the effectiveness reflected in research on residential treatment (Hair, 2005).  This apparent contradiction points to the difficulty in evaluating whether a complex setting works or not.  The answer often depends upon the way the question is framed, as well as how outcomes are measured.   

There has been decades of research evidence of efficacious treatment of children and adolescents in all settings.  When children who receive a broad variety of treatments are compared with control groups of children receiving no treatment, the treatment group is consistently superior with an effective size from .7 to .8 (Casey & Berman, 1985; Baer & Nietzel, 1991; Burns, Hoagwood & Mrazek, 1999; Grossman & Hughes, 1992; Hazelrigg, Cooper & Borduin, 1987; Kazdin, Siegel & Bass, 1990; Shadish, Montgomery, Wilson, Wilson, Bright & Okwumabua, 1993; Weisz, 1987; Weisz, Weisz, Han, Granger & Morton, 1995).  Some treatments and some settings have shown better results than others, but treatment efficacy research provides strong and consistent evidence that providing psychological treatment to child clients is much better than not doing so. 

Much has been made of the scarcity of causal research on residential treatment.  The reason that effectiveness research on residential settings has been either mixed or lacking is primarily due to the complex weave of multiple treatments in an ecological setting.  Such an enriched setting of multi-modal treatment variables is not conducive to empirical causal research.  Moreover, “the very characteristics that are likely to make (treatment) effective make them more difficult to describe and evaluate…numerous elements of family and agency life weave together with the therapeutic intervention and potentially decrease the chance of finding a positive treatment effect when there is one” (Hair, 2005). Butler and McPherson point out that this lack of empirical evidence in part is based upon the challenge of measuring what residential care does best.  They report gains such as:  enhanced safety, truancy reductions, consistent medication management, reduced hospitalizations, consistency, structure, caring and nurturing, limit setting, psychosocial support, self-esteem role modeling, time to self-reflect, and focus on mental health issues, all of which are invaluable to the child but are complicated to objectify and analyze. “Thus the literature does not actually reveal much helpful information” (Butler & McPherson, 2006). 

Some of the research showing marginal or no positive efficacy makes the conceptual error of comparing some new type of treatment intervention with the traditional treatment setting of residential care.  There are studies that indicate poor outcomes with residential care (Burns et.al., 1999; Greenbaum et.al., 1996; Friman, 2000; Ruhle, 2005).  Some of these studies again address a setting, not specific treatment interventions.  Research on essentially all settings can find poor outcomes (families, hospitals, foster care, schools, etc.). For example, while there is considerable evidence of effectiveness for some uses of family based treatment foster care, other uses have been found to be contraindicated (Farmer, Wagner, Burns & Richards, 2003), or less effective for some populations than residential care (Drais-Parrillo, 2005). Treatment settings in themselves do not insure effectiveness, this can only be done by quality interventions within a treatment setting.              

When treatment interventions are the subject of research residential settings the results often show strong improvement (Landsman, Groza, Tyler & Malone, 2001; Hooper et. al., 2000; Weiner & Kupermintz, 2001; Burns et.al., 1999).  Research has shown long-term maintenance of gains in clinical functioning, academic skills and peer relationships (Blackman, Eustace & Chowdhury, 1991; Joshi & Rosenberg, 1997; Wells, 1991). 

Two predictors of long-term positive outcomes deserve to be specifically mentioned.  The quality of the therapeutic relationship in therapy has been found to be one of the most important predictors of long-term success (Pfeifer & Strzelecki, 1990; Scholte & Van der Ploeg, 2000).  In a recent study on attachment representations, children in residential treatment improved in their forming secure attachments and decreasing their avoidance and hostile behavior.  However this finding was true only for children with longer stays in residential treatment.  The study reported, “When the duration of treatment is extended, the personal attachment backgrounds of clients and treatment staff increase in importance (Zegers, Schuengel, van IJzendoorn & Jansserns, 2006).  The other long-term predictor of success is positive outlook, life satisfaction and hopefulness.  In a 2006 study children in residential treatment increased their hopeful thinking and general well-being, while decreasing psychopathology (McNeal, Handwerk, Field, Roberts, Soper, Huefner & Ringle, 2006). Attitudinal and cognitive variables such as hope have been found to predict outcomes above and beyond psychopathology (Hagen, Myers & MacKintosh, 2005). This study on hope found the children with the highest levels of psychopathology made the most gains after 6 months of residential care. 

Therefore a quick statement on the general findings of research indicate: strong support for providing treatment services to child over no treatment, mixed results when evaluating the setting, and strong support for effectiveness with specific treatments in residential settings.  It can therefore be said that, in general, treatment provided to the child will be better than none at all, and it is the treatment interventions used in the residential setting that are the determining factor of efficacy and not the setting itself. 

The Right Target Population for Psychiatric Residential Treatment 

Intensive treatment services in a residential setting are restrictive and potent and should only be a part of the plan of care for a child if needed.  There is common agreement that care should be taken before placing a child out of a family setting and particularly when placing the child in a PRTS program.  It is important that guidelines exist concerning the right target population while not being so prescriptive that children ‘fall through the cracks.’  To avoid legislating children out of a needed service, it is essential that the individual child’s needs must come first, and the child matched to the proper level of care intensity.  The overall criteria for such a restrictive setting is to include only those children who cannot receive the treatment they need while remaining in a family setting.   The historical criteria for admission to PRTS have been: 

  1.  Other treatment resources available in the community do not meet the treatment needs of the child.
  2. Proper treatment of the child’s psychiatric condition requires services in a psychiatric residential treatment setting under the direction of the psychiatrist.
  3. The services can be reasonably expected to improve the child’s condition or prevent further regression so that psychiatric residential services may no longer be needed
  4. The child has a principal diagnosis of Axis I of a completed 5-Axis DSM diagnosis that is not solely a result of mental retardation or other developmental disabilities, epilepsy, drug abuse, or alcoholism. 

These criteria have provided guidelines while allowing for individual needs to be considered.  If proper treatment resources exist in the community, if the child does not need psychiatric oversight, if the treatment can help or prevent further deterioration and if they child has a mental health diagnosis, then the child can be considered.  As the system focuses on improving community resources, more children would be screened out due to the first criteria. 

The one screening tool that has been used in the past is the Childhood Acuity of Psychiatric Illness.  It has been used to inform the admission and discharge decisions but has not been the sole criteria.  Like the CASII, where it is possible to have an overall low acuity score yet be appropriate for intensive treatment due to high risk behavior, the CAPI scores do not address all areas of need or interest when making admission decisions.  Therefore it cannot be used solely as an indication of proper or improper placement decisions. 

There is general agreement that treatment should be individualized, strength-based, and integrated.  Therefore it is important to insure that admission and discharge decisions are individualized and not based upon a score or single or multiple indicators not related to the needs of the child. 

It is important that the child have a serious mental health issue to be appropriate for PRTS.  However, the treatment needs of the child should be the primary consideration and not the diagnostic category, which often varies by practitioner.  Frequently a child’s diagnosis changes when the provider changes.  Diagnostic categories are not discreet in many cases and children needing PRTS care typically have multiple Axis I diagnoses. The diagnosis of a child at admission has been found to be a negligible factor in success at discharge (Hair, 2005), thus the specific diagnosis should not be used as a factor to screen a child in or out of PRTS. For example, lf a child is dangerous due to a mental health diagnosis, the child should not be screened out due to which diagnosis the child has been given.  Using another example, if a child is suicidal and has a serious oppositional defiant diagnosis, the child should receive the treatment needed in a safe setting, which could necessitate a PRTS level of care, regardless of the diagnosis. 

Research consistently indicates that children with supportive families do better in general, do better in school, do better in treatment, and do better coming out of PRTS.  This makes logical sense.  However, true trauma informed care necessitates that a child who is unlucky enough to receive poor family support or who has lost his or her biological family, should not be further neglected by the system and prevented from receiving PRTS care if that is the indicated need.  Developing an aftercare resource becomes an important part of the plan of care.  Trauma informed care also requires that the treatment reflects the child’s past, provides effective trauma treatment, and insures safety, predictability, and stability of placement while intensive trauma treatment is provided.  For a seriously traumatized child, focusing solely on stabilizing a child’s behavior without providing intensive trauma treatment is not individualized, nor is it responsive to the needs of the child and family. 

Summary 

Psychiatric residential treatment is an important and essential component of the mental health system of care.  The best treatment programs are ecological in orientation and combine all the needed components to best help the child and family.  Despite the fact that ecological treatment settings are not conducive to quantitative causal research designs, they have been shown to be some of the most effective services for children with multiple needs.  Psychological treatment has shown decades of strong support across settings and has been shown effective when interventions in residential settings are considered rather than the setting itself.  The family must be involved in both decision making and intensive treatment along with the child.  If a child has lost his or her family for whatever reason, the child should not be further neglected by not receiving the level of intensive treatment services needed.  The right target population should be afforded PRTS.  Adhering to the historical criteria has shown that the right children receive the right level of care.  Reliance on any one score, instrument or factor alone is contraindicated for PRTS as it is for any placement decision for a child.  The admission decision on a child must be individualized with the needs of the family taken into consideration.  The treatment must conform to the child and family and not expect the child to conform to the treatment.  This includes both treatment programs as well as the overall system of care.  When a PRTS program is carefully designed with multi-modal treatments to address the complex needs of the child, and individualized in partnership with the family, this intervention can turn the most seriously challenging children in the system of care into some of the most improved consumers.  Such an outcome is one that is desirable to all stakeholders in the system of care.  

References 

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Burns, B.J., Hoagwood, K. & Mrazek, P.J.  (1999).  Effective treatment for mental disorders in children and adolescents.  Clinical Child and Family Review, 2, 199-254. 

Butler, L.S. & McPherson, P.M.  (2006).  Is Residential Treatment Misunderstood?  Journal of Child and Family Studies. 

Blackman, M., Eustace, J. & Chowdhury, T.  (1991).  Adolescent residential treatment:  A one to three year follow-up.  Canadian Journal of Psychiatry, 36, 472-479. 

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Farmer, E.M., Wagner, H.R., Burns, B. J. & Richards, J.T.  (2003) Treatment foster care in a system of care: Sequences and correlates of residential placement. Journal of Child and Family Studies, 12, 11-25. 

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Grossman, P.B. & Hughes, J.N.  (1992).  Self-control interventions with internalizing disorders:  A review and analyses.  School Psychology Review, 21, 229-245. 

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Hagen, K.A., Myers, B.J. & MacKintosh, V.H.  (2005).  Hope, social support, and behavioral problems in at-risk children.  American Journal of Orthopsychiatry, 75, 211-219. 

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Handwerk, M.L. (2002).  Least restrictive alternative: Challenging assumptions and further implications.  Children’s Services: Social Policy, Research & Practice, 5, 99-103. 

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Joshi, P.K. & Rosenberg, L.A.  (1997).  Children’s behavioral response to residential treatment.  Journal of Clinical Psychology, 53, 567-573. 

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Landsman, M.J., Groza, V., Tyler, M. & Malone, K.  (2001). Outcomes of family-centered residential treatment.  Child Welfare, 80, 351-379. 

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Leiberman, R.E. (2004). Future directions in residential treatment.  Child and Adolescent Psychiatric Clinics of North America, 13, 279-294. 

Leichtman, M.  (2006).  Residential treatment of children and adolescents:  Past, present and future.  American Journal of Orthopsychiatry, 76, 285-294. 

Leichtman, M. & Leichtman, M.L.  (1996).  A model of short-term residential treatment: General Principles and Changing Roles.  In W. Castro (Ed.), Contributions to residential treatment, 1996.  Alexandria, VA:  American Association of Children’s Residential Centers. 

Leichtman, M., Leichtman, M.L., Barker, C.B. & Neese, D.T.  (2001).  Effectiveness of intensive short-term residential treatment with severely disturbed adolescents.  American Journal of Orthopsychiatry, 71, 227-235. 

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Lyman, R.D. & Wilson, D.R.  (1992).  Residential and inpatient treatment of emotionally disturbed children and adolescents.  In C.E. Walker & M.C. Roberts (Eds.), Handbook for clinical child psychology (2nd ed.),  Oxford, UK: Wiley Publishing. 

McNeal, R., Handwerk, M.L., Field, C.E., Roberts, M.C. Soper, S., Huefner, J.C. & Ringle, J.L. (2006).  Hope as an outcome variable among youth in a residential care setting.  American Journal of Orthopsychiatry, 76, 304-311. 

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Ruhle, D.M.  (2005).  Take care to do no harm:  Harmful interventions for youth problem behavior.  Professional Psychology: Research and Practice, 36(6), 618-625. 

Scholte, E.M. & Van der Ploeg, J.D.  (2000).  Exploring factors governing successful residential treatment of youngsters with serious behavioral difficulties:  Findings from a longitudinal study in Holland.  Childhood: A Global Journal of Child Research, 7, 129-153. 

Shadish, W.R., Montgomery, L.M., Wilson, P., Wilson, M.R., Bright, I & Okwumabua, T.  (1993). Effects of family and marital psychotherapies: A meta-analysis.  Journal of Consulting and Clinical Psychology, 61, 992-1002.  

Shapiro, J.P., Welker, C.J. & Pierce, J.L. (1999).  An evaluation of residential treatment for youth with mental health and delinquency-related problems.  Residential treatment for Children and Youth, 17, 33-48. 

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Surviving and Thriving in a Difficult Adoption

By Dave Ziegler, Ph.D.

Adoptions can be much like marriages:  Too many dissolve with pain for everyone; others stay together but everyone is unhappy; some get by with everyone lowering his or her expectations; and too few are a wonderful experience of loving, learning, and growing for all concerned.  To foster success, adoptions need as much care, thought, and skill training as marriages.  Marriages and adoptions fail partly because those involved do not know what they are actually saying yes to and discover they don’t have what it takes to handle the reality they find.  The goal becomes not only how to survive the reality of the adoption but how to thrive with the challenges involved. 

Maintaining More than Your Sanity 

Maintaining a healthy adoption can be compared to maintaining an automobile.  There are issues that need attention, and, as the ad goes, “You can pay me now or pay me later.”  Here are some comparisons:

Check the radiator                      Keep it cool, don’t overheat              
Check the steering/brakes       Stay in control at all times                   
Keep the battery charged         Keep your energy                              
Tune up for performance          Maintain your power                         
Check the plugs                         Keep your spark                             
Check wear on tires                  Realize you are wearing down before you burst. 

Contained in each of these suggestions is all you really need to know about maintaining health in an adoption.  The best truths are simple ones.  A recent best seller tells us that we learned in kindergarten everything we need for a happy, fulfilled life.  Well, some of us may have gotten it all the first time, but most of us could use a refresher.  If you got it all at first, then stop here.  But if you need to hear a bit more, read on. 

Why Do Adoptions Fail? 

There are many reasons for disrupted adoptions, but they all boil down to one overall issue.  Families choose to adopt for many reasons, but they want to do a good thing for all concerned.  Although they know there will be struggle, they do not adopt to put everyone through great pain.  Adoptions fail when a commitment to a child begins to harm commitments to other loved ones.  If it gets to the point that something has to go, it will probably be the adopted child.  There are two important perspectives here: 

The family.  There may be many reasons to adopt, but in the end a family decides it has room in its members’ lives and hearts for a new family member.  But what are they to do if their offers of love and affection are met with lack of interest or even hostility?  The family can understand that life may have been difficult for the child but believe all that can change if the child simply accepts the loving care of this new family.  After weeks and then months of a child letting the family know that he or she wants neither their home nor their heart, all that the adoption seems to be bringing everyone is pain.  Maybe the child would be better off somewhere else, and clearly the family members were better off before all this started.  This often becomes the final chapter, one filled with failure, guilt, and grief for everyone. 

The child.  All adopted children have experienced deep loss or they wouldn’t need a family.  Most special-needs children have experienced much more than loss.  Fearful and adrift in the foster care system, the child is informed that he will soon get a new family.  But do people realize what family may mean to the child—the ones that were supposed to always be there for you but weren’t?  To the child, Mom and Dad may mean someone who didn’t care, or worse, someone who was very abusive.  The child has probably been in numerous homes and schools.  Such children can’t put their heart on the line again unless they know it will be safe, so they test the family.  Sometimes their testing is misinterpreted by the family, and a negative cycle begins.  The worse it gets, the more fear arises and then more testing occurs.  The child begins to see the family stop trying and waits for the caseworker to appear and once again move the child from a home that was supposed to always be there for him or her but wasn’t.  This confirms again that the world is a cruel place where you have to fight to survive and avoid being vulnerable at all costs.  And the world has another antisocial personality. 

How can these traps be avoided?  How can the process not only last but be a good experience for everyone? 

What Successful Adoptions Look Like 

Successful adoptions involving a child with special needs tend to have a lot of TLC.  Tender loving care, you say?  Absolutely not!  Tender loving care is almost always in abundant supply in failed adoptions with these children.  That just may be one of the principal problems.  In this case TLC means something very different: 

T = Translating correctly what is really going on with the child in order to understand where the child really is.  It is commonly known that manipulative teenagers (and aren’t they all) talk in opposites.  It is often a safe bet to retranslate what they are saying to get closer to the truth.  Practice by retranslating the following:  I don’t want rules; I’m not worried about my future; I am all caught up on my schoolwork; I’ll be home early tonight.  This same principle works with special-needs children. 

L = Learning from the challenges of adopting a difficult child becomes one of the indicators of success, not how smooth it’s going for everyone.  If you want smooth, get some Jell-O.  But adopting is not smooth—it is trouble or challenge, depending on your point of view.  The more you see it as a challenge to learn from, the better the candidate you are to adopt a difficult child.   

C = Stay in control at all times in all situations involving the child.  These children did not get difficult on their own; they had lots of help from chaotic, abusive, and neglectful families that could not provide a safe or secure home.  Constant control sounds pretty heavy, but if you adopt one of these children, he or she will constantly test to see just how in control you are.  If the child is able to gain control, everyone loses; if the child can’t, everyone wins.  It’s that simple. 

TLC – Translating, Learning and Control – is easier said than done.  But here is part of the point – what does a difficult adoption offer you?  It offers an opportunity to grow yourself, as you give a deserving child a fresh chance to be part of a family. 

Seven Strategies for Success 

1.  Understand the real needs of the child.  It is not often helpful to listen to the child’s words or even to accept the child’s behavior at face value because of the opposite issue.  If the child has had an abusive or neglectful past, then his or her needs are pretty straight-forward despite the way the child acts.  These children need the following:            

  • Safety.  Will I be safe in a nonviolent environment where my basic needs will be met?           
  • Security.  I need a structured situation where a parent is in charge and I can just be a kid.           
  • Acceptance.  I need people who can accept me as a person even if they don’t like or accept my behavior.           
  • Belonging.  I need to belong to someone; I need to be connected to others and learn to give and receive affection.           
  • Trust.  I need to learn to trust and be trusted; I need to be treated fairly, with honest, to respect, and firmness.           
  • Relationship.  I need to be in relationships with others in a way that no one is victimized and both sides are enhanced.           
  • Self-awareness.  I need to learn how to make changes in my personality and behavior by self-understanding.           
  • Personal worth.  The final indicator of my being a success as a person is, Do I believe in myself and my own worth? 

2.  Positive discipline is the quickest route to your control and to the child’s personal worth.  Techniques include separate the child from the behavior; don’t punish—discipline (which means to teach); don’t let “time-outs” become a disguised punishment; use logical consequences; don’t ask the child to lie by asking questions you know the answer to; avoid power struggles; have the child fight with himself/herself, not with you; keep your sense of humor and don’t let the child decide what you will feel; and allow the child to change and be more responsible by not always locking the youngster into past behaviors. 

3.  Learn to win the manipulation game.  Don’t let the child use your rules against you.  Don’t be completely predictable to a manipulative child; you’ll become an easy target.  Keep the child off balance when he or she is trying to beat you.  In general, if the child is manipulating to get something, do your best to prevent the child from getting his or her way or you will get more manipulation (because it worked).  Stay a couple of steps ahead by predicting what the child might do and what you will do in return.  Don’t respond emotionally; you won’t think very creatively then.  Parenting is best done by a team; talk over your next move and get advice and ideas.  If the child has you on the run, the child will win the manipulation game and both of you will lose. 

4.  Get the help you need from the right source.  Quite frankly, some counselors who don’t understand these children can make the situation considerably worse.  It is not much of a challenge for a manipulative child to be “perfect” an hour a week in someone’s office.  If the counselor starts looking at you like you must be the problem, get someone else.  Ask prospective counselors about their experience with adoption, abused children, and kids with attachment problems.  Or better yet, go to a counselor who comes highly recommended for his or her skills with a child just like yours.   

5.  The only given is that this type of adoption will be difficult; it does not have to be terrible.  The difference is something you have complete control over – your feelings and sense of humor, the world just isn’t funny anymore,” and adoption is like that. 

6.  Make sure you are more than a parent.  If you are a parent twenty-four hours a day, you have become pretty dull.  Be a wife, a student, a hiker, a volunteer, a square dancer, an artist, a husband, or whatever, but don’t get stuck in the parent role where there is a whole lot more giving than receiving.  Batteries don’t last long if they never get recharged. 

7.  Don’t get in a hurry.  The saddest failed adoptions are the ones where the child is desperately testing and the parents call it off.  If only they could understand that the desperation is an indicator that the testing is nearly over and that they have almost passed the test.  It has taken a long time for these children to be hurt; it takes time for them to be vulnerable again.  But don’t continue down a road that is clearly leading nowhere.  Get some good help from a counselor who has a good road map – there may be a much better road to get where you want to go. 

Final Thoughts 

So what do you think?  If it sounds like a lot more work than you thought, don’t feel alone.  Just consider – if parents knew all they would have to endure with their birth children, would they be so eager to go through with it?  Make no mistake – parenting is the world’s most complex and difficult job.  It is even more challenging if you have to pick up the pieces that someone else has failed with.  If all this is more than you can imagine, then get a pet.  But if you want the ride of your life, if you want to be the most substantial influence in a young person’s life, and if you want to learn more about yourself than you thought was possible, then boy, does CSD have a deal for you!  

So You Have a Challenging Child in Your Home?

By Dave Ziegler, Ph.D.

Dave Ziegler is the founder and executive director of Jasper Mountain, a nationally recognized treatment program for traumatized children.  Dave is a psychologist and holds four professional licenses and has been a foster parent for many years.  In addition to his work at Jasper Mountain, he speaks throughout the country as well as internationally to parents and professionals.  Dave is the author of five books, including Raising Children Who Refuse To Be Raised, Traumatic Experience and the Brain, Beyond Healing: The Path To Personal Contentment After Trauma, and Neurological Reparative Therapy: A Roadmap to Healing Resiliency and Well-Being.  This article is drawn from his 2005 book Achieving Success With Impossible Children, Winning the Battle of Wills.

If you have a challenging child in your home, you are not alone.  With the numbers of children in foster care, the increased number of domestic and foreign-born adopted children, and children in biological homes that have experienced divorce and other domestic problems, parents today are searching for answers to the increasing challenges presented by troubled children.  Some of these children can make parents crazy, because parenting approaches that work for other children don’t help at all; and even worse, what worked with the child yesterday, doesn’t work today.  Sound familiar?

I know what you are thinking, “another one of those articles about being a good parent-with an expert saying: be consistent, stay calm and make sure the child gets plenty of tender loving care.”  Not so fast, in some cases this advice is a part of the problem rather than a part of the solution.  And if you haven’t already asked this, I will do it for you, “So what makes this guy an expert anyway?”  Good question.  There is only one thing that makes someone an expert in parenting difficult children and that is to have actually done it, and done it successfully.  Starting as a foster parent with one child at a time, my home has evolved into one of the top treatment centers in the United States. The type of children we go out of my way to help are those that refuse to ask for, or even accept, our attempts to help or to parent them.  Perhaps I have a screw loose, but I see these children as my best teachers.  So if your child is happy to see you when she comes home from school, if he volunteers to help out around the house for free and can be found on weekends cleaning his room while singing “Don’t Worry, Be Happy,” then this article is not for you.  I hear stories about such children, but I have never parented one.  My foster home turned into a group home, and then into a treatment center over the years.  But my family is still here 23 years later getting children who are grumpy (and worse) off to school each morning, and seeing if we can introduce each of them to a world they don’t believe exists-one where they can come out a winner.  Do they eventually get it?  Yes, in nearly every case.  But before they learn to touch the stars, they have to learn to firmly plant their feet on the ground.  If you are with me so far, then let’s get to work on parenting difficult children.

What I have found that works with troubled and difficult children is a combination of staying focused on the goal for each child, and knowing what I need to be doing more of, and what I need to be doing less of.  My goal is a progression of having each child experience the following and to do so in the correct order-experience safety, security, acceptance, belonging, trust, relationship, self-understanding and personal worth.  These critical components of being a successful human being must come one at a time as in stair steps, and rely on the foundation of the step that came before.  Without safety you can’t have security, without acceptance you cannot feel like you belong, and without trust you cannot have a successful relationship.  I ask myself what step I am on with each child I am working with and keep focused on the goal to get to the next step-one child and one situation at a time.

What I need to be doing more of can be broken down to the following: 1. Translate the child’s behavior and energy to understand what is going on inside of him (don’t get sucked into his words, works are seldom helpful), 2.  Give attention to things I want to see more of (don’t spend your day giving most of your energy to misbehavior, because what you give attention to, you get more of), and 3. Lead with thinking and not with emotions (don’t let the child decide how you are going to act or feel, remember that feelings are easy targets for children who want to wound others).

So what about being consistent, staying calm and tender loving care?  I find consistency overrated.  This is not the case with responsive children, because they need your consistency.  With troubled, angry and/or manipulative children, they will use your consistency against you.  To disrupt a child who gets stuck in the same negative behavior habits, I suggest creative inconsistency.  What this means is you must first disrupt the cycle between you and the child.  He is used to doing his thing (misbehavior) and waiting for you to do your thing (correcting the behavior).  You don’t like this cycle, but your child does like it because he feels in control of you and the environment.  If you are tired of this dance, then change it.  First short circuit the behavior pattern, and then intervene more effectively.  For example, if your bundle of joy has a habit of not liking dinner each night and colorfully sharing her culinary review, then start the dinner by saying, “Jessica, you only get dessert tonight when you have found something wrong with every aspect of tonight’s dinner.”  After the child looks up at you wondering, “Has she finally lost it?” she then has a dilemma (that I love to put children in)–do I follow directions and criticize, or do I refuse to criticize and break my pattern.  You win either way.  We call this prescribing the symptom, and it can also be called putting the child into a therapeutic bind.  The goal is not to frustrate the child, but the goal is to frustrate the behavior.

Most parenting classes will tell you to stay calm.  That is fine most of the time.  However, when I get ignored by children (this is frequent in the early stages), or if the child wants me to repeat essentially everything I say, I might try yelling my thoughts and directions.  I don’t do this in an angry way, just a loud way.  Troubled children do not like yelling in the house if the yelling isn’t coming from them, so they always ask me, “Why are you yelling?”  I tell the child that I am saving us both the time of either repeating or having them miss what I have to say.  When they ask me to stop it, I offer them a deal that I don’t need to yell if they listen and don’t need things repeated.  Welcome to the world of reciprocity.

As for tender loving care, the quickest way for a child to put a parent in the funny farm is to reject every overture of caring and love.  Love may have been all the Beatles needed, but they were not raising troubled children.  Difficult children need love all right, but it needs to come in the form of teaching the child the lesson that life and relationships are two-way streets, what we put out to others has a lot to say about what we get back.  So save your tender loving care until the child has moved beyond manipulation, self-hate and perpetual rudeness (yes, with the right steps they can move beyond these).  In the meantime give them a different type of TLC-Translating what is going on with them, Learning from every situation to be a better parent to this child, and staying in Control of your behavior, your emotions and the energy in your household.

With those basics as a foundation, let’s look at a number of strategies for successful parenting:

  • Take care of yourself-if you don’t do it, who will?  We all have rechargeable batteries, but like a flashlight, if we don’t take the time to recharge, our light becomes dim in a hurry.
  • See below the surface of behavior-what you can see is only a small part of the problem.  Behaviors are the result of what a child thinks and how he or she feels.  We must go deeper than managing behavior.
  • Be firm in a loving way-if we are too firm the child links us with past abuse, if we are too loving they may not respect us.  Strike a firm and friendly balance.
  • Never stop working on yourself-we all make mistakes parenting?  I use my mistakes as a model for children.  I admit the mistake and take personal responsibility, and then I take the necessary steps to repair any damage done.  How can we ask a child to do this if adults have not taught the child how by example?
  • Make sure the child feels your support-don’t wait until things go badly before showing your support.  When things do go badly, with every correction give the child the message you believe that he or she can do better.  “We don’t grab things from others just because we want it in this house.  I want you to think about this and I know you can come up with a better way to handle it.  When you do, let me know and you can have your turn.”
  • Always give more praise than criticism-criticism fits the child’s negative self-image, praise does not.  If you want the child to be more positive, he must hear more positive messages from you.
  • Practice the “New Day”-just because the child has been doing poorly in the past, start over each day and give them a chance to improve.  If the child is ready to move beyond misbehavior, make sure you are ready to let them.  This is one reason why extended consequences, such as grounding the child until age 21, are not recommended.
  • Don’t let the child lower your expectations-you generally get somewhat less than you expect from a difficult child.  If you expect a lot or a little, you will get somewhat less.  High or low expectations, its your call (by the way, the child prefers lower expectations).
  • Practice “No-Lose Parenting”-do your home work, use your superior mental skills, do your best, don’t give up, don’t expect an immediate return on your investment in the child, and remember, your responsibility is what you have become more so than who the child chooses to become.  If you do all this, how can you lose?

OK, so I haven’t told you everything you need to know to be successful with your difficult child.  Fair enough, so the little challenge in your home is going to take some extra study and work?  That is why this parenting approach has two textbooks with very appropriate titles:  Raising Children Who Refuse To Be Raised and Achieving Success With Impossible Children.  The ideas in these books can change the whole game with your child.  Working with tantrums, sexual behavior, lying and stealing, and teaching responsibility, positive discipline, are all covered in the style of this article. Obviously I believe the ideas will help you.  I believe this because the ideas were all taught to me not in graduate school but by the children I have parented.  Did I forget to say, parenting a difficult child can even be fun?  You will have to read more to find out about that (I warned you about my loose screws).  Happy parenting!